- Research and analyze electronic and manual claims. Apply troubleshooting skills to resolve issues as allowed by the individual benefit.
- Communicate prior authorization criteria to providers.
- Act as a provider help desk specialist to aid providers in submitting prior authorization requests, providing formulary product information, and communicating prior authorization request status.
- Develop and maintain knowledge of Medicare D, Medicaid, and/or Exchange programs
- Respond to and resolve all internal and external inquiries in a timely, accurate, and complete manner.
- Utilize all available resources to ensure that the correct and complete answer is given to all inquiries.
- Prioritize work appropriately and as assigned by leadership.
- Learn and apply processes and changes to those processes.
- Learn, abide by, and help enforce all departmental procedures.
- Actively participate in team meetings, coaching sessions, and daily operations.
- A high school degree or equivalent. Post high school education desired such as L.P.N., Certified Pharmacy Technician, Medical Terminology, or Medical Transcriptionist.
- Previous customer service experience required.
- Previous data entry experience preferred.
- Experience in health insurance/pharmacy insurance or managed care organization preferred.
- Prior authorization processing experience desired.
- Experience in a PBM or managed care call center desired.
- Experience in a mail or retail pharmacy setting desired.
- Experience with Medicare and/or Medicaid regulatory guidance desired.
- Participate in, adhere to, and support compliance program objectives
- The ability to consistently interact cooperatively and respectfully with other employees
- Hours/Location: Schedules Vary, Remote
- Paid Volunteer Hours
- Educational Assistance Plan and Professional Membership assistance
- Referral Bonus Program – up to $750
- Top of the industry benefits for Health, Dental, and Vision insurance, Flexible Spending Account, Paid Time Off, Nine paid holidays, 401K, Short-term and Long-term disability, College Savings Plan, Paid Parental Leave, Adoption Assistance Program, and Employee Assistance Program
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Specialist I, Prior Authorization-Remote - Appleton, United States - Navitus Health Solutions LLC
Description
Job Description
Job DescriptionPutting People First in Pharmacy- Navitus was founded as an alternative to traditional pharmacy benefit manager (PBM) models. We are committed to removing cost from the drug supply chain to make medications more affordable for the people who need them. At Navitus, our team members work in an environment that celebrates diversity, fosters creativity and encourages growth. We welcome new ideas and share a passion for excellent service to our customers and each other.
We are unable to offer remote work to residents of Alaska, Hawaii, Maine, Mississippi, New Hampshire, New Mexico, North Dakota, Rhode Island, South Carolina, South Dakota, West Virginia, and Wyoming.
The Specialist I, Prior Authorization (PAS) will review, process, and troubleshoot incoming Prior Authorization requests for various medications. The Specialist I, Prior Authorization (PAS) will accurately process the requests according to regulatory and client specific guidelines. The PAS will work with other team members to meet the departmental performance metrics and maintain compliance. The PAS will work with clinical to ensure requests are processed accurately and timely. The PAS will process requests that come in via phone, fax, and web submission.
The Specialist I, Prior Authorization (PAS) will become proficient in the Navitus claim processing system, at least one of the Prior Authorization processing systems, and Intranet. The PAS will gain proficiency in understanding, applying, and communicating client-specific formularies, clinical programs, regulatory guidance, and other pharmacy benefit components. The PAS will learn and understand general pharmacy benefit management and health care industry terminology and practices.
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